Linee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer

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1 Linee guida sul trauma cranico: sempre attuali? Leonardo Bussolin AOU Meyer

4 Vavilala MS, et al Retrospective multicenter cohort study Prehospital Arena ED OR - ICU Each 1% increase in adherence was associated with a 6% drop in the hazard of death and a 1% drop in the hazard of being severely disabled or vegetative

5 PROTOCOL FOR MANAGEMENT OF THE SEVERE BRAIN INJURY Summary protocol Surgical measures Coma barbiturate Mild hyperventilation Mannitol Hypertonic saline Fluids and pressors, optimize sedation Monitor ICP and optimize parameters

7 Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent Second Edition Changes in recommendations from the first edition to the second edition First Edition (2003) Second Edition (2012) Corticosteroids III - The use of steroids is not recommended for improving outcome or reducing ICP in severe TBI; despite two class II studies failing to show efficacy, the small sample sizes preclude support for a treatment guideline for this topic II The use of corticosteroids is not recommended to improve outcome or reduce ICP in severe TBI

9 Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent Second Edition Changes in recommendations from the first edition to the second edition Analgesics, Sedative, and Neuromuscolar Blockade First Edition (2003) Second Edition (2012) III In the absence of outcome data, the choice of dosing and sedative, analgesic, and neuromuscolar agents should be left to the treating phisician III Etomidate may be considered to control severe intracranial hypertension; however the risks resulting from adrenal suppression must be considered - III Thiopental may be considered to control intracranial hypertension - In the absence of outcome data, the specific indications, choice, and dosing of analgesic, sedative, and neuromuscolar agents should be left to the treating phisician - Continuous infusion of propofol is not recommended

11 Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent Second Edition Changes in recommendations from the first edition to the second edition Temperature control Temperature control Temperature control Temperature control Temperature control First Edition (2003) Second Edition (2012) III - From adult data, hyperthermia should be avoided - III - Despite the of clinical data in children, hypothermia may be considered in refractory intracrania pressure II Moderate hypothermia (32-33 C) beginning early for only 24 h duration should be avoided II Moderate hypothermia (32-33 C) beginning within 8 h for up to 48 h duration should be considered to reduce intracranial hypertension II If hypothermia is induced, rewarming at a rate of > 0.5 C per h should be avoided III Moderate hypothermia (32-33 C) beginning early for 48 h duration may be considered

12 MANNITOL vs HYPERTONIC SALINE

14 Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent Second Edition Changes in recommendations from the first edition to the second edition First Edition (2003) Second Edition (2012) Hyperosmolar therapy - Hyperosmolar therapy Hyperosmolar therapy III - Continuous infusion of 3% hypertonic saline ml/kg/h with the minimum dose needed to maintain ICP <20 mmhg III - Mannitol is effective with bolus doses range gr/kg II 3% Hypertonic saline in severe TBI with intracranial hypertension: ml/kg III - The same + serum osmolarity should be maintained below 360 mosm/l Although Mannitol is commonly used no studies meeting inclusion criteria were identified for use as evidence for this topic

15 2010; 5:18-21 Role of hypertonic saline and mannitol in the management of raised intracranial pressure in children: A randomized comparative study Piyush Upadhyay, VN Tripathi, RP Singh, D Sachan Mannitolo 3%Hypertonic

16 Bennet TD, et al. Crit Care Med (1):

17 SaO 2 :100% vs PtbO 2 : 20 mmhg

21 PaCO2

23 Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent Second Edition Changes in recommendations from the first edition to the second edition Hyperventilation First Edition (2003) Second Edition (2012) III Mild or prophylactic hyperventilation (<35 mmhg) in children should be avoided Hyperventilation III -Mild hyperventilation (PaCO mmhg) may be considered for longer periods for intracranial hypertension refractory to sedation and analgesia, neuromuscolar blockade, cerebrospinal fluid drainage, and hyperosmolar therapy Hyperventilation Hyperventilation III - Aggressive hyperventilation (PaCO2<30mmHg) may be considered as a second-tier option for refractory hypertension; cerebral blood flow, jugular venous oxygen saturation, or brain tissue oxygen monitoring is suggested to help identify cerebral ischemia III Aggressive hyperventilation titrated to clinical effect may be necessary for brief periods in case of cerebral herniation or acute neurological deterioration III Avoidance of prophylactic severe hyperventilation to a PaCO2 < 30mmHg may be considered in the initial 48 h after injury III If hyperventilation is used in the management of refractory intracranial hypertension, advanced neuromonitoring for evaluation of cerebral ischemia may be considered

25 MAP/CPP

27 Guidelines for the Acute Medical Management of Severe Traumatic Brain Injury in Infants, Children, and Adolescent Second Edition Changes in recommendations from the first edition to the second edition First Edition (2003) Second Edition (2012) CPP II - CPP > 40 mmhg should be maintained III A CPP between 40 and 65 mmhg probably represent an age-related continuum fo the optimal treatment threshold; there may be exceptions for this range in some infants and neonates III Advanced cerebral physiological monitoring may be useful to define the optimal CPP in individual insatnces III A minimum CPP 40 mmhg may be considered III A CPP threshold mmhg may be considered; there may be age-specific thresholds with infants at the lower end and adolescents at the upper end of this range

28 Brady KM, et al. Pediatrics 2009;124:e1205 Pressure-Ractivity Index

31 VASOSPASM IN CHILDREN?

34 J Neurosurgery Pediatr 2015 Mar;15(3): pazienti 8 mesi-18 anni ESA PT e RA CONCLUSIONS: Children have a relatively high incidence of angiographically detectable, moderate-to-severe CV. Children rarely develop symptomatic CV and have good long-term outcomes, perhaps due to robust cerebral collateral blood flow.

35 Heffren J et al Mar;52(3): CONCLUSIONS: Oral nimodipine after subarachnoid hemorrhage in children does not eliminate vasospasm, rebleeding, or infarction and is associated with significant hypotension. Nevertheless, clinical outcomes appear favorable relative to the adult population who receive nimodipine. Further study, with dose titration, is warranted.

Traumatic Brain Injury:

Traumatic Brain Injury: Changes in Management Across the Spectrum of Age and Time Omaha 2018 Trauma Symposium June 15, 2018 Gail T. Tominaga, M.D., F.A.C.S. Scripps Memorial Hospital La Jolla Outline Background